Provider Demographics
NPI:1598781718
Name:MYCKATYN, TERENCE MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:TERENCE
Middle Name:MICHAEL
Last Name:MYCKATYN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-7388
Mailing Address - Fax:833-301-0853
Practice Address - Street 1:1020 N MASON RD
Practice Address - Street 2:DIV SURG PLASTICS, MOB 3 STE 110
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6666
Practice Address - Country:US
Practice Address - Phone:314-362-7388
Practice Address - Fax:833-301-0853
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001737492082S0099X, 2086S0105X, 2086S0122X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207820606Medicaid
ILENROLLEDMedicaid
MO041010543Medicaid
IL$$$$$$$$$Medicaid